Vaginal Surger y for Pelvic Orga n Prolapse
Stephen B. Young, MD
KEYWORDS Pelvic organ prolapse Reconstructive surgical procedures Hysterectomy Vaginal Cystocele Rectocele
The art and science of vaginal reconstructive surgery has evolved during the past 2 centuries. The first vaginal hysterectomy was performed for malignancy by Langenbeck in 1813,1 although there is much controversy surrounding this. The surgical treatment of prolapse developed through multiple varied operations in the second quarter of the nineteenth century. Early procedures were somewhat or fully obliterative. The more prominent were largely occlusive and included elytrorhaphie--removing long vertical vaginal strips and placing several supportive sutures, cauterization of the vagina, episiorrhaphy--where dependent parts of the labia majora were removed and the raw surfaces united resulting in almost complete vulvar occlusion, perineorrhaphy, and cervical amputation, finally full cervical removal with bladder displacement.1 In America, the first vaginal hysterectomy for prolapse was performed by Samuel Choppin in New Orleans in 1861. Before the introduction of general anesthesia and aseptic technique, these early procedures were limited. Operations had to be brief as pain was not fully alleviated. A general imprimatur reigned against entering the peritoneal cavity for fear of peritonitis. Gradually, over the next 100 years, as the theory of pelvic organ prolapse etiology and pathophysiology developed, and more definitive curative surgical procedures could be performed safely, the operations that became popular in the early part of the twentieth century were established. These include procedures such as the standard anterior colporrhaphy with Kelly plication suture for cystocele and urinary incontinence. For several decades, vaginal hysterectomy has been generally accepted as the approach of choice for removal of the benign uterus. Ribeiro and colleagues,2 in an randomized control trial (RCT) published in 2003 concluded, ``vaginal hysterectomy presents superior results in terms of operative time and inflammatory response
Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics & Gynecology, UMass Memorial Medical Center, University of Massachusetts Medical School, 119 Belmont Street, Worcester, MA 01605, USA E-mail address: youngs01@ummhc.org Obstet Gynecol Clin N Am 36 (2009) 565�584 doi:10.1016/j.ogc.2009.08.013 0889-8545/09/$ � see front matter � 2009 Elsevier Inc. All rights reserved. obgyn.theclinics.com
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when compared with total abdominal and laparoscopic hysterectomy and should be the first option for hysterectomy.'' This article is meant to be a pragmatic how-to guide in the performance of standard vaginal reconstructive operations. The sequencing mirrors that which occurs in the operating room. It will deal exclusively with techniques for the vaginal approach to pelvic organ prolapse correction. Most of the procedures described are based closely on the teachings of Dr David Nichols.
EXAMINATION UNDER ANESTHESIA
With the patient in lithotomy position but not yet Trendelenburg, separation of the lateral vaginal walls with two medium Breisky-Navratil retractors will afford a quality view of the anterior compartment. One may note the presence of any anterior prolapse and determine if it is caused by a midline, transverse (superior), and/or lateral (paravaginal) defect. Cervico-uterine prolapse can be seen and uterine mobility noted by tenaculum traction. Bimanual exam is used to determine uterine size, shape, and mobility; presence, location, and size of myomata; and pelvic capacity. Of particular importance is the adequacy of the subpubic arch. A narrow subpubic arch will compromise the operator's ability to perform meaningful vaginal surgery. Adnexal masses can be palpated. Next, with a Deaver retractor elevating the anterior compartment, the posterior wall can be assessed. Any possible weakness can be further defined with a digital rectal exam. Importantly, the presence and extent of defects in the vaginal outlet and perineum should be judged. Vaginal outlet relaxation, perineal deficiency, and possible introital scars can be corrected at the end of the procedure with a careful perineorrhaphy. There is a significant difference in the prolapse findings on examination under anesthesia (EUA) and those in an ambulatory setting. Although one can be more thorough in both observation and palpation, still, the absence of the Valsalva effort removes the active component that manifests and maximizes the clinical prolapse. Significant differences have been reported in the findings of EUA versus those of ambulatory pelvic exam.3,4 The completion of the EUA is the appropriate moment to strategically plan the order of procedures and surgical tailoring to achieve vulvovaginal dimensions that will afford optimal coital function.
VAGINAL HYSTERECTOMY Simple
A Lone Star Self-retaining Retractor (Lone Star Medical Products, Stafford, TX) with yellow and blue stays is extremely useful for exposure. Over a weighted speculum, the cervix can be grasped with two Jacobs tenaculae and infiltrated at the vaginal/ epithelial junction with local anesthetic such as 0.5% bupivacaine with 1:200,000 epinephrine solution. With the goal of leaving the vagina as long as possible, a fullthickness circular incision is made around the cervix using either a curved Mayo scissor or scalpel. With scissors slightly open, achieving a full-thickness incision is confirmed by the ability to easily push the vaginal skin cephalad. Hemostasis is obtained and the posterior peritoneum is grasped with a Debakey forceps between the uterosacral ligaments and incised, thus entering the posterior cul-de-sac. Digital exam of the posterior peritoneal surfaces reveals the characteristics of the uterosacral ligaments, the size and freedom of the posterior uterine surface, and the presence of any cul-de-sac or uterine adhesions or masses. One is now ready to begin securing the uterine pedicles (Fig. 1).
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Fig. 1. The left uterosacral ligament is grasped with a Zeppelin clamp.
Using a Zeppelin, Masterson, or Heaney clamp, the uterosacral and cardinal ligament pedicles, as they insert onto the cervix, are separately grasped, cut, sutureligated with 0-Vicryl, and held. This is usually an optimal time to enter the anterior cul-de-sac. The curved Mayo scissor held perpendicular to the cervix is used to incise its anterior covering connective tissue (supra-cervical septum) from 11 to 1 o'clock. It is usually necessary to sever the more vascular connections immediately lateral (bladder pillars). This can be done with cautery. At 12 o'clock, the Mayo scissor, now held closed parallel and immediately anterior to the cervix, will slide cephalad, posterior to the bladder and just anterior to the peritoneum of the anterior cul-desac. An index finger will confirm location and a Deaver will maintain exposure. Often the anterior peritoneum is not yet easily accessible. Although the anterior cul-desac itself may not be opened, the bladder and ureters are now elevated out of harm's way. The ureters can be palpated most easily after the anterior peritoneum is opened (see the section ``Ureteral palpation''). Attention is returned to the uterine pedicles where the uterine vessels can now be secured. The same Zeppelin and 0-Vicryl suture ligature technique is used, but the pedicles are not held. After another pedicle or two on each side, the adnexae come into view with a normal-size uterus. Their pedicles are secured and the uterus handed off. A free tie of 0-Vicryl, 1 cm proximal to the instrument will, with instrument ``flashing,'' compress the pedicle before the suture ligature. The needle is placed centrally, behind the instrument, and both treads passed around the instrument's tip and tied behind its heel. If further adnexal traction is required, an additional distal 2-0 Vicryl suture can be placed and held.
Ancillary Techniques for the Large Uterus
Uterine myomata very often complicate vaginal hysterectomy. Simply by the nature of their size, making the uterus larger than the pelvic canal or by their awkward location in relationship to the placement of hysterectomy pedicles, fibroids can be singular or multiple, small or very large; submucosal, intramural, subserosal or pedunculated; located at almost any position on the uterus or cervix; and may appear in a host of different degenerative conditions. The presence of uterine myomata alone does not form a contraindication to vaginal hysterectomy. However, when fibroids make a uterus larger than 12 to 14 weeks gestational size, a careful plan of action is indicated in accomplishing the vaginal approach to hysterectomy. It is difficult to state an absolute size above which one ought not consider vaginal hysterectomy. One always has to consider the size of the passageway (the pelvis) in relationship to the
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passenger (fibroid uterus), as well as the location and size of the individual myomata. Is it one large fibroid or are there multiple small myomata? With experience in the ancillary maneuvers of intramyometrial coring (Lash procedure), cervical amputation, bivalving, wedging, and myomectomy, a considerably enlarged uterus can be reduced in size such that it is easily and safely deliverable vaginally. Before any of these maneuvers are performed, securing of the uterosacral, cardinal, and uterine vascular pedicles are essential prerequisites. Once the uterine vessels are secured and, hopefully, the anterior and posterior cul-de-sacs have been entered, large myomas of the corpus and fundus may soon limit the securing of more apical pedicles. At this point a Lash procedure with or without cervical amputation will convert a very large, globular fibroid uterus into a more manageable ovoid-shaped structure. Using a Beaver blade, a continuing circular incision is carried up from the lower uterine segment, at least 1 cm in from the serosa and parallel to it, toward the fundus. Gentle traction is applied on the inner uterine specimen with triple-tooth Lahey-type tenaculae. This should be done slowly as danger lies just outside the serosa. Deviating somewhat too medial and entering the endometrial cavity, however, is not a problem. A cautery on cutting function may be intermittently substituted for the Beaver knife. But here, even greater care must be used. As one progresses, the fundus in the midline will become palpable. At this point, the uterine specimen is usually deliverable and the ovarian suspensory ligaments and fallopian tubes can be clamped. In a very large uterus with multiple myomata, the Lash with or without cervical amputation may not be adequate to reduce the uterus to a deliverable size. Individual myomas encountered along the way can easily be shelled-out via their pseudocapsule and handed off. If the posterior or anterior uterine aspect is particularly dominant, a large wedge may be excised. If all these maneuvers still leave an undeliverable specimen, the remaining uterus can be cut in half vertically or bivalved. This affords two more manageable pieces.
VAGINAL ADNEXECTOMY
After removal of the uterus and cervix, and the intestinal contents packed with the patient in Trendelenburg position, Breisky retractors will normally demonstrate the adnexa at 3 and 9 o'clock. Maintaining minimal traction on an additional distal suture on the adnexal pedicle eases its removal. After gently grasping the ovary with a Babcock, a free adnexa can be safely removed with a LigaSure (ValleyLab, Boulder, CO) type of device, an endoloop and transfixation suture, or a clamp/cut/suture process using an instrument such as the infundibulopelvic (IP) Zeppelin clamp. Filmy adhesions may be sharply lysed. It is often less of a technical challenge to remove the ovary separate from its Fallopian tube.
URETERAL PALPATION
One must become beware of the path of the ureter. Upon entering into the anterior cul-de-sac, this is an ideal point to palpate the ureter through part of its pelvic course. One ought to locate it again before placing the first anterior colporrhaphy suture and at any point during the entire surgery where one may be within close proximity to it (2 cm). Fig. 2 depicts a ureteral palpation technique. Gynecologists are concerned about avoiding the ureter near the uterine vessels during vaginal hysterectomy. A site where it is even in closer proximity to operative maneuvers is at the initial suturing of an anterior colporrhaphy where it may be within 0.9 cm.5
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Fig. 2. Ureteral palpation technique during vaginal surgery. One method is to begin identification from within or just outside of the anterior cul-de-sac. The dominant index finger tip begins just lateral to the tractioned Foley balloon (urethrovesical junction). It moves 3 to 4 cm cephalad and lateral, at a 30 angle toward the same shoulder, to the area of the ipsilateral uretero-vesical junction. The ureter is felt by gentle index fingertip palpation as its volar aspect slides down in an arc posterior and lateral from 10:30 o'clock on the right side, slowly toward a vaginal Deaver tip at 9:00. One often senses one's fingertip run over the ureter as a nonpulsatile, somewhat mobile, cylindrical tube--quite akin to a cooked spaghetti strand, as it approaches the Deaver. Alternatively, it may snap at the edge of the Deaver tip or just over its anterior surface. It is generally felt 2 to 4 cm away from the vaginal incision. If not palpable this way, it may be felt between two index fingers, one inside and one outside the anterior vaginal wall. They are placed as high as they can get and gently, slowly brought down--frequently encountering the ureter along their way (From Young SB, Kambiss SK. Anterior wall support defects. In: Bent AE, Cundiff GW, Swift SE, editors. Ostergard's Urogynecology and Pelvic Floor Dysfunction. 6th edition. Philadelphia: Lippincott, Williams & Wilkins; 2008; with permission.)
VAGINAL VAULT SUSPENSION
Whichever method one chooses to suspend the vaginal vault following a hysterectomy is, perhaps, less important than actually performing some definitive culdeplasty procedure. The vaginal apex, preferably anterior and posterior apices, should be secured with delayed-absorbable or permanent suture to an intact component of the uterosacral-cardinal connective tissue complex. As connective tissue breaks may exist in the more distal vaginal ends of the cardinal-uterosacral ligament condensation, as part of prolapse etiology, it seems logical to use more cephalad portions of these structures to suspend the vaginal cuff.
McCall (New Orleans) Culdeplasty
Suspending the vaginal apex to the uterosacral ligaments was first published by Miller6 in 1927. McCall7 described his culdeplasty procedure while in New Orleans in 1957. He sutured the vaginal cuff to the uterosacral ligament remnants after vaginal hysterectomy as a means of maintaining normal support of the vaginal apex. This procedure was modified over the next several decades at the Mayo clinic and elsewhere and
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now has many different variations. McCall culdeplasty modifications are aimed at physiologically maintaining vaginal length and axis and closing the cul-de-sac. Delayed-absorbable and/or permanent sutures sew the distal uterosacral ligament (USL) to the posterior vaginal apex and peritoneum. A single suture secures both uterosacral ligaments and posterior vaginal apices and reefs across the posterior peritoneum between the ligaments, obliterating the posterior cul-de-sac in the process. A wedge of mid-posterior vaginal wall apex can be excised if redundant. Two or more McCall sutures may be placed ``internally''--intraperitoneally and through the ``internal'' aspect of the vaginal apices. An additional ``external McCall stitch'' is placed similarly, but is brought through the full-thickness of the vaginal skin into the apical lumen on both sides.
High Uterosacral Suspension
Although the McCall culdeplasty is effective in maintaining apical length and axis,8,9 it is not known as a definitive therapeutic reconstructive operation for uterine descent with accompanying vaginal vault prolapse or posthysterectomy vaginal vault prolapse with enterocele. The high uterosacral suspension is such an excellent procedure that we ordinarily use it both therapeutically, for posthysterectomy vaginal vault prolapseenterocele and prophylactically, to suspend the apex immediately following vaginal hysterectomy. By placing gentle traction on the held uterosacral ligament pedicle in 180 opposite direction, the intermediary portion of the uterosacral ligament can be palpated, usually running 1.5 cm medial and posterior to the ipsilateral ischial spine. The middle third of the uterosacral ligament is chosen as the fixation point because it has been shown to be both stronger and farther from the ureter than the distal (vaginal) third.10,11 The separation between this intermediary portion of the uterosacral ligament and both the lateral aspect of the rectum and the ipsilateral ureter can be palpated. A long Allis clamp can be placed on the distal end of the uterosacral ligament for stabilization and assistance in suturing. With the patient in moderate Trendelenburg position and the bladder emptied, the bowel is packed away with 1-inch peritoneal moist pack and excellent exposure obtained using a Light-Mat on a Deaver retractor anteriorly and a Miyazaki lighted retractor posteriorly. The Deaver holds away the packing and bladder while the Miyazaki guards the rectum. A headlamp is an optional feature to give even more illumination to the pelvis. We use a 0-PDS and a 0-Prolene on a CT-2 needle held in the strong jaws of a 14-inch Nolan needle driver, sewing from anterior to posterior, going through and not around the intermediary portion of the uterosacral ligament, and retrieve the needle with a separate long, straight needle driver. The suture is passed from anterior to posterior on each side. The packing and lighted retractors are removed. Any redundant posterior peritoneum or enterocele sac can be excised. Similarly, if the posterior vaginal cuff is redundant, a wedge can be removed with cautery without compromising significant vaginal length. The eight ends of these four sutures are sewn, one PDS and one Prolene each, to the right and left posterior and anterior cuffs. The PDS is sewn from inside the incision out to the vaginal lumen and back in, going through the full thickness of the vaginal wall. The Prolene sutures are rather sewn in a manner that obtains purchase on the fibromuscular layer of the vagina and spares the lumen, also from inside to inside. The addition of a free #5 Mayo-needle on the suture arm without one makes these maneuvers simpler. These four sutures can then be held, to be tied after completion of an anterior colporrhaphy. The Velcro strips that come in the laparoscopy drapes, which we use in vaginal surgery, will adhere to
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each side of the Lone Star Retractor. The suspension sutures will remain straight in the Velcro straps, avoiding the otherwise ever-present tangling. Just before tying the suspension sutures it is useful to have the bladder empty, mild Trendelenburg, and wet gloves. We tie the Prolene suspension sutures first, as the knot moves the most easily and is least apt to catch. Then the PDS sutures are tied. If free mesh has been placed in the anterior compartment, for example in recurrent cystocele repair, the PDS suspension sutures can be brought through the apical aspect of the mesh before tying. The sutures are held and not cut. Cystoscopy with Indigo Carmine (1 amp IV), will demonstrate projective blue flow from both ureteral orifices if patent. If one or both ureters fail to produce dye-stained urine, one should serially remove sutures, including anterior colporrhaphy and vault suspension until the dye appears. Ureteral stenting is sometimes indicated. We then examine the cuff to see if additional cuff closure is necessary between the suspension sutures. If it is, cutting all but the lateral two suspension sutures and tractioning them will make the cuff more accessible for closure.
CYSTOSCOPY WITH DYE
The bladder should be thoroughly viewed during any incontinence or anterior and/or apical vaginal reconstructive operation. A 70 or 30 cystoscope will work well to view the internal anatomy and function of the trigone, ureteral orifices, and the remainder of the bladder mucosa. Intravenous indigo carmine (5 mL) may take from 3 to 15 minutes to appear, in a projectile manner, from the ureters. Ibeanu and colleagues12 have recently shown that the indigo carmine dye from the ureteral orifices need not be projectile to have confidence that the ureters are functional.
Enterocele Repair
The problem of posthysterectomy vaginal vault prolapse and enterocele can be addressed either abdominally with a sacrocolpopexy or vaginally with an enterocele repair and vault suspension. The vaginal approach will be discussed here. One can approach a posthysterectomy vaginal vault prolapse and enterocele either apically with an elliptical incision around the cuff or via the Nichols' approach--transperineally, using a curved-Mayo scissor dissection of the superficial posterior vaginal skin from the underlying connective tissue and old obstetrical scar, working cephalad to gain entry into the rectovaginal space. Whichever approach is chosen, dissection in the superior aspect of the rectovaginal space will reveal the possible enterocele sac. A small or even moderately sized enterocele, particularly in a woman with obesity and one or more previous pelvic operations, may be quite difficult to differentiate from the anterior rectal wall or other surrounding tissues. Gentle manipulation of this potential sac with a Russian forceps, while the opposite index finger is flexed in the rectal ampulla, will usually assist in identification. Sharp entry into the sac is confirmed with two small Breisky retractors showing bowel. The neck, or narrowest portion of the peritoneal hernia, is easily noted. Superficial to that, the redundant peritoneum of the enterocele can be dissected and removed. A thorough high uterosacral ligament vaginal vault suspension performed at this point will elevate the vaginal cuff and peritoneal neck and also effectively close it. Alternatively, one can place a formal peritoneal purse-string suture for closure of the enterocele sac at its neck. Prior to the high uterosacral ligament vaginal vault suspension becoming a dominant vaginal reconstructive operation, enterocele sacs were typically ligated at their neck, after identification, incision, and dissection, with a delayed-absorbable or permanent purse-string suture. Before placing the purse-string
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suture, one would carefully palpate both ureters. Then, the surgeon could be sure to purposefully avoid them during purse-string placement. In a purse-string suture, 8 to 10 bites through the peritoneum and the subperitoneal retinaculum are taken all at the same level, ending with the last bite very near the first. The ends are held. If a uterosacral suspension has been done, these culdeplasty sutures would be tied before tying the purse-string. At this point, a cystoscopy with dye would demonstrate ureteral patency.
Sacrospinous Fixation
There are advantages to performing vaginal sacrospinous fixation (SSF) for apical prolapse: it restores a functional vagina with a normal, horizontally inclined upper vaginal axis (albeit deviated, particularly if SSF is unilateral) resting on the levator plate.13 Because it is an extraperitoneal procedure, compared with abdominal sacrocolpopexy and requires less operative time, it has a lower rate of postoperative ileus, intestinal obstruction, incisional pain, and other transabdominal surgical risks. A disadvantage of the SSF is its 23% rate of postoperative anterior compartment prolapse. When performing SSF, we recommend placing the sutures into the sacrospinous ligament (SSL) under direct visualization rather than by palpation. Following completion of a hysterectomy, if indicated, we make a V-shaped incision in the perineum. The skin and posterior vaginal wall are dissected from the perineal body until the avascular rectovaginal space is entered. After making matching parallel incisions in the cephalad direction on the posterior wall, the redundant segment is excised. At this time, we open, mobilize, and resect, then close any enterocele sac. This procedure may be performed either unilaterally or bilaterally; a right SSF will be described. The right rectal pillar separates the rectovaginal space from the right pararectal space and has two layers of condensed areolar tissue. The SSL is located deep within the coccygeus muscle, which runs through the pararectal space from the ischial spine to the sacrum. Easy exposure of the coccygeus muscle�SSL complex depends on how thick the rectal pillar is and whether it is fused or exists as two distinct layers. The right rectal pillar is perforated 1.5 fingerbreadths posteromedial to the ischial spine. If the pillar is weak or thin, it may be easily pierced with one's fingertip; otherwise, we use scissor tips or tonsil forceps. We insert our middle and index fingers through a ``window'' in the rectal pillar into the right pararectal space. The medial tip of the middle finger should touch the medical surface of the ischial spine. Exposure is achieved with a Breisky or Nichols retractor anteriorly and another medially. Extra viewing and suturing space may be secured with a Vital Vue suction/irrigation light laterally. To pass the suture, one may use either a Capio transvaginal suture-capturing device (Boston Scientific, Natick, MA), Nolan or other heavy needle-driver, Miya hook ligature carrier (Zinnanti Surgical, Woodland Hills, CA), Deschamps ligature carrier, or Shutt suture punch (Conmed Linvatec, Largo, FL). Regardless of which instrument is used, we pass the sutures through--rather than around--the ligament, 2 fingerbreadths medial to the ischial spine, to avoid the posterior gluteal vessels, the lateral sciatic nerve, and the pudendal neurovascular complex. Using the Miya hook, two sutures may be passed simultaneously. One absorbable and one nonabsorbable are recommended. After passing the sutures through the SSL, we catch them with a nerve hook and cut the loop in the center and pair each end with its respective free suture. One method of bringing the softer, more mobile vagina to the surface of the coccygeus muscle and ligament is the ``pulley-stitch.'' We sew the anterior ends of the sutures to the undersurface of the posterior vaginal apex. The vaginal suture end is
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tied to itself, making the posterior apex a fixed point. The posterior limb of the sacrospinous stitch is left free. We then begin the upper portion of the posterior vaginal skin closure, closing the upper 2 inches. Using traction on the posterior limb of the suture, we pull the vaginal apex directly into the coccygeus muscle and sacrospinous ligament and use a square knot to fix it in place. With a simple square knot, the second or ``safety'' stitch can be readily tied. Posterior colporrhaphy and perineorrhaphy, if indicated, are then completed. The vagina may then be lightly packed with gauze for 24 hours.
ANTERIOR COLPORRHAPHY Incision
The anterior wall is elevated with Allis clamps in the midline at any point where one can grasp it atraumatically. Intracutaneous infiltration with a 0.5% bupivacaine/1:200,000 epinephrine, using a 30-gauge needle is carried out until the peri-incisional area is fully blanched. The anterior wall is incised from apex to 1 cm short of the urethral meatus and proximally to the apex. If a mid-urethral sling is to be placed, the incision should stop 1 cm proximal to the urethrovesical crease. If anterior colporrhaphy is performed with vaginal hysterectomy, circumferential cervico-vaginal incision can be followed by midline anterior full-thickness incision between two Allis clamps halfway toward the urethral meatus. Early proximal dissection (either full or split-thickness, Fig. 3) at this point demonstrates local anatomy to ease safe anterior cul-de-sac entry. Following hysterectomy and culdeplasty, one returns to the anterior dissection. Absent hysterectomy, the same full-thickness curved Mayo scissor midline vertical incision directly into the vesicovaginal space is used and extended from apex anteriorly to 1 cm short of urethral meatus, as the two Allis clamps grasp and advance along the cut-edge. Retracting the skin edges with blue Lone Star stays will improve exposure.
Dissection
Now in the vesicovaginal space (VVS) with excellent exposure and lighting, the next step is dissection. It may be effectively performed via two alternative depths (see Fig. 3). The bladder may be dissected from the full-thickness anterior vaginal wall, developing and remaining in the VVS. This is the anterior equivalent of the Goff posterior colporrhaphy dissection.14 Alternatively, the dissection from the VVS may split the anterior vaginal wall between the epithelium and the muscular-adventitial layer, as it is performed posteriorly in the split-thickness Bullard modification (preferred by this author).14 This technique leaves a distinct layer of vaginal fibromuscularis/adventitia between bladder and vaginal epithelium for separate repair. This dissection path, if continued laterally, just under the ischiopubic rami, gains entry into the retropubic, paravesical space for the vaginal paravaginal repair. Sharp technique throughout is advised whether using full- or split-thickness dissection depth. One or two Allis clamps hold the vaginal skin edge above (distal to) the line of dissection. The operator's nondominant hand holds the clamp(s) with that index finger at the outside location of the vagina where it is being dissected inside. The dominant hand holds a curved Mayo scissors and that index finger stabilizes the fulcrum of the scissors. In a real sense, the outside index finger communicates data to its inside counterpart regarding depth of dissection. There are many technical features that can only be adequately exchanged in the operating room. In general, we find it best to keep the scissors parallel and next to the curve of the inner vaginal
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Fig. 3. Two depths of anterior dissection/repair. 1. Layers of the anterior vaginal wall and bladder on schematic cross-section; from vaginal lumen going into bladder lumen (B) in the following manner: E, vaginal epithelium; M, vaginal muscularis; A, vaginal adventitia merging into bladder adventitia, bladder muscularis, bladder mucosa. The solid line represents the full-thickness (F-T) vaginal incision into the VVS, whereas the dotted line shows the incision's continuation towards the apex. 2. S-T. In the split-thickness (S-T) or Bullard anterior dissection, a plane is sharply dissected between the E and the M, whose A/P and lateral limits are individually determined. A large prolapsing bladder may be inverted with a 3-0-polygalactin pursestring and imbricated with one or more running or interrupted suture lines in the bladder serosa. Repair strength comes from 2-0 polydioxanone running suture of M. Medially redundant E (x) is trimmed. 3. S-T. E closure with running 2-0 polygalactin. 2. F-T. Dissection plane in this full-thickness (F-T) Goff dissection is between vaginal A and bladder A (shared by both organs). As in 2.S-T, prolapsing bladder is imbricated. F-T medial vagina is excised (x). 3. F-T. Repair strength comes from F-T 2-0 polydioxanone interrupted sutures. (From Young SB, Kambiss SK. Anterior wall support defects. In: Bent AE, Cundiff GW, Swift SE, editors. Ostergard's Urogynecology and Pelvic Floor Dysfunction. 6th edition. Philadelphia: Lippincott, Williams & Wilkins; 2008; with permission.)
wall, as one cuts and pushes with very little use of spreading, using traction and countertraction, looking to find and enlarge (develop) a potential plane. Traction on whatever tissue is being dissected off the vagina (vaginal muscularis or bladder) toward the contralateral side reveals small sites of vaginal attachment to incise. The assistant uses a Russian-type atraumatic forceps to give gentle countertraction, thereby demonstrating the exact connective tissue/skin attachment site to incise. The countertraction on attached connective tissue frequently creates a triangulated appearance, with the narrow end attached to the inside vaginal skin to be cut. Immediately after a definite plane is established (white, hypovascular, shiny), the flexed dominant index fingertip is inserted into that plane, to that point where the plane ends and the fingertip is extended against the vaginal undersurface. This will deepen and enlarge the dissected plane. This act is in complete counterdistinction to wrapping a Ray-tec sponge around one's index finger and with or worse, without an open plane, bluntly pulling the vaginal muscularis or bladder off the epithelium; such a rough, blunt dissection act ought to be avoided. The dissection may be ended halfway to the level of the ischiopubic rami, or carried laterally part or all the way to the rami. We prefer to carry sharp dissection laterally out
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to the level of the medial aspect of the ischiopubic rami, apically to the anterior fornix or cuff, and distally to the periurethral connective tissue. The distal dissection limit must often be modified if a concomitant anti-incontinence procedure is to be performed. Similarly, one may not wish to disturb a well-supported anterior vault. There is, at least a theoretical issue over performing a central repair, especially apically, when a paravaginal defect may have been missed. The anterior colporrhaphy may be seen to aggravate an ongoing lateral defect. Could this be one of the many possible factors responsible for the high (29%) rate of recurrent pelvic organ prolapse (POP) surgery?15 There exists, therefore, an ethical and clinical imperative to get the site or sites of anterior wall defect on clinical exam and EUA ``right the first time.'' Venous bleeding can be encountered anywhere during anterior compartment dissection, but can be most troublesome lateral to the urethrovesical junction. The minor vessels of the incision or the more apical dissection can be fully controlled with cautery or hemostat/forceps and cautery. However, the larger paraurethral venous sinuses, especially those proximate to the anterior aspect of the inferior pubic ramus, require more attention. Figure-of-eight sutures may effectively surround these low-pressure complexes, and the knots are brought down gently. We use 2-0 polygalactin on a UR-6 (5/8 circle urologic) needle passed on a Heaney needle driver in this tight space to surround the bleeding sinus while making the acute curve complete short of the bone. Direct pressure on several ray-tec sponges for 2 to 5 minutes may stop the ooze. If that fails, a very effective technique uses triangular strips of Gelfoam-100 (Pharmacia & Upjohn, Bridgewater, NJ), placed narrow-end first with a dressing forceps into ``the bloody angle'' between the ramus, pubic bone, and bladder and is almost uniformly successful.
Repair
Regardless of the depth of dissection and repair about to be performed, exposure in the VVS allows optional plication and imbrication of a large prolapsing bladder and its adventitia. This reduces the width of the VVS, but adds little strength to the repair. It may be first plicated with a purse-string or other type running 2-0 polygalactin or polyglycolic acid suture and imbricated with an interrupted or running second and sometimes third layer of the same material. The strength of the repair comes from the next layer. In the Goff full-thickness repair, the weakened distended excess medial vaginal wall is excised. Then, the repair's strength comes from suturing the undersurface of the more lateral full-thickness anterior vaginal wall where the muscular-adventitial tissue has been left connected to the epithelium. Using Bullard's split-thickness technique, the dissected muscular-adventitial vaginal layer over the bladder is carefully examined. Generally, poor tissue and specific tears related to pathophysiology or dissection are noted and strategies for correction developed. Individual, site-specific tears are repaired with interrupted 2-0 polydiaxonone. The entire dissected layer can be brought together and reinforced in the midline using one or two layers of interrupted or running 2-0 polydiaxonone. Skin redundancy can be trimmed and the edges of the vaginal epithelium brought together with running 2-0 polygalactin.
PARAVAGINAL REPAIR
George White published in 190916 and Cullen Richardson and colleagues in 197617 established that a major aspect of vaginal support consists of lateral connective tissue attachments from the lateral sulci of the anterior vaginal wall to the arcus tendineus fascia pelvis (ATFP). Disruptions of these attachments can be corrected with high
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success rates using the paravaginal repair be it via vaginal,18,19 abdominal,20,21 or laparoscopic approaches.22,23
VAGINAL PARAVAGINAL REPAIR
The vaginal paravaginal repair uses permanent sutures around the ATFP, under direct observation within the retropubic/paravesical space by careful dissection from the vesicovaginal space. Maximum exposure and lighting are critical. Use of the Lone Star retractor with yellow and blue hooks, a laparoscopy drape with two Velcro straps on the medial thighs, catheterized bladder, empty rectum, and a weighted speculum are all important. Additional lighting instruments that we use include the Vital Vue Gyn-tip (United States Surgical, a division of Tyco Healthcare, LP) and the Miyazaki lighted retractor (Marina Medical, Hollywood, FL). The lateral limit of the anterior colporrhaphy dissection, the ischiopubic ramus, is the beginning of the paravaginal dissection. First the ischial spine is palpated laterally under the apical end of the ramus. Naturally, its anterior facet feels different than it usually does from a posterior perspective. Running one's dominant index finger medially, anterior, and cephalad, the operator comes to the inferolateral pubic bone. It is not quite as distinct as the anterior aspect of the spine, and feels like a rough corner. These two points are critical because they mark the boundaries of the linear archus tendineus to which one will reattach the vaginal anterior lateral sulcus. At 1 to 2 cm anterior to the spine, slight lateral, perpendicular pressure on a closed curved Mayo scissor, just under the ramus and over the volar aspect of the nondominant index fingertip very gently opens a small window into the retropubic space (RPS). This window is enlarged minimally with cautious scissor and finger-tip dissection, before gently placing serially sized Breisky or Deaver retractors anteriorly and a Miyazaki lighted retractor medially--all very deliberately just within the window. Proof that the dissection is correctly in the RPS is obtained by demonstrating the pelvic sidewall, retropubic fat, and the fatty cylindrical obturator neurovascular bundle descending at the far limit of the exposure. The ATFP is prepared for suturing by carefully retracting the bladder medially with the Miya lighted retractor and the ureter and anterior abdominal wall anteriorly with a Deaver (preferably wrapped with a Lite-Mat). A posterior Breisky is optional. One tries to obtain optimal exposure before placing arcus sutures. Nevertheless, one must be extremely cautious with forward movement of the retractor tips. If the long retractor tips are adjusted forward, without direct observation by the surgeon, they are at high risk of endangering large veins. Damaged paravaginal attachments result in an ATFP that is quite variable to palpation and appearance. Palpating between the two landmark limits of the arcus will show whether it is present or has been torn away from the sidewall. In the latter case, we suture in the same manner as if it were present. The line (arcus) that is or was between the two bony prominences, serves as a series of points, 1 cm apart. Each point marks the center of a circle around which a 0-grade permanent suture is sewn, having a diameter of 2 cm, and is passed perpendicular to the ATFP. The CT-1 type needle pass may begin with a 1-cm 90 curve on either the obturator internus or levator ani side, turning widely around the real or surmised arcus and turning back 90 widely to include a 1-cm pass through the other muscle. We begin suturing 1.5 cm anterior to the spine (Fig. 4) and move up 1 cm apart toward the pubic bone with each successive vaginal paravaginal repair (VPVR) stitch. Four to six sutures are placed on each side in a complete bilateral paravaginal defect. We use a Nolan needle driver and long straight needle driver for needle retrieval. Alternatively, some prefer the Capio Suture Capturing Device (Boston Scientific, Natick, MA). Gentle traction in the opposite
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Fig. 4. Vaginal paravaginal repair: First suture. A, Arcus tendineus fasica pelvis (ATFP); B, obturator internus muscle; C, levator ani muscle; D, obturator neurovascular bundle; E, retropubic fat. (From Young SB, Kambiss SK. Anterior wall support defects. In: Bent AE, Cundiff GW, Swift SE, editors. Ostergard's Urogynecology and Pelvic Floor Dysfunction. 6th edition. Philadelphia: Lippincott, Williams & Wilkins; 2008; with permission.)
direction on the arcus suture should give the sense of a secure purchase. Any doubt mandates a second slightly deeper throw while placing mild traction on the first throw. The ATFP sutures are kept parallel in Velcro straps. Before sewing the arcus sutures to the vagina and bladder, we perform the anterior muscularis plication and other anterior compartment procedures as indicated. The ATFP sutures are then sewn to the connective tissue layers of the bladder and the vagina at matching levels. For each of these two points, we locate halfway between the ramus and the midline. Sewing the vagina and bladder to the ATFP at points too lateral results in an inadequate lift. Choosing points too medial yields a very dramatic anterolateral elevation of a vagina that one cannot close. But sewing and tying at the midpoints yields dramatic anterolateral lift and tension-free skin closure. Any remaining slight excess epithelium is trimmed and the vagina closed with running 2-0 polyglycolic acid or polygalactin suture.
TRANSVERSE DEFECT REPAIR
Following vaginal hysterectomy, the anterior vaginal wall is shorter than the posterior wall because of cervical excision. The connective tissue supports of the proximal anterior vagina will also be weakened if there is a transverse defect (TD). This leaves a large anterior apical gap and an even larger area without a muscular-adventitial layer. Repair of the TD (TDR) is performed as part of the culdeplasty. When supporting the apex and orienting the vault more horizontally over the levator plate with the high (or deep) uterosacral ligament vaginal vault suspension (HUS), one must remember the importance of lifting the anterior as well as the posterior vault. It is important to
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repair a transverse defect and cervical gap as well as to support the proximal anterior wall. Many techniques accomplish this.24,25 Is the inclusion of the anterior apical skin in the HUS adequate to close the cervical gap and repair the transverse defect? Do we not often leave a significant anterior apical gap in women suffering from transverse defect? The technique that follows is one possible method to repair a TD, close the cervical gap, and help suspend the anterior apex. One or two 0-polydiaxonone or polypropylene sutures support, close, and elevate the anterior and posterior lateral apices to the mid-cardinal ligament bilaterally, while a midline suture connects both anterior and posterior apices, right and left sides (Fig. 5). During a preliminary vaginal hysterectomy, the cardinal ligament pedicle must be taken in a manner similar to preparing the uterosacral ligaments for HUS. Essentially, this means palpation and pedicle preparation such that the cardinal ligament pedicle will be free of vessels, yet its support value maximized. After completion of the anterior repair, a running suture is used to close the anterior wall. It is tied with 2 cm left open at the midline apex. The TDR suture picks up the fibromuscular layer and the undersurface of the right anterior lateral apex. The ureter is repalpated. A Breisky retractor will expose the cardinal ligament pedicle. Then the suture is placed through the cardinal ligament from up to down, 2 cm proximal to the ligature. It is then sewn, similarly to the right posterior lateral apex. After the contralateral TDR stitch has been placed, the midline suture obtains purchase on both
Fig. 5. Transverse defect repair. The first TDR stitch starts anteriorly. It is placed 1 to 2 cm from either lateral apex: 1 cm from the cut-edge, starting inside. Next, a secure bite is taken, at least 2 cm up from the cut-edge of the cardinal ligament pedicle. The anterior lateral apical bite is repeated as a mirror image at the posterior lateral apex, ending inside opposite the suture's anterior entry point. Before anterior and cardinal bites, the ureter can be re-palpated. After placing one suture on each side, a central suture is placed 1 cm off both midline and cut-edge, securing both anterior and posterior apices. Simulation of tying by crossing the three TDR stitches will define the need for a second lateral suture on one or both sides. (From Young SB, Kambiss SK. Anterior wall support defects. In: Bent AE, Cundiff GW, Swift SE, editors. Ostergard's Urogynecology and Pelvic Floor Dysfunction. 6th edition. Philadelphia: Lippincott, Williams & Wilkins; 2008; with permission.)
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sides of anterior and posterior apices. If a posterior apical wedge has been excised, this must be considered. The HUS, with or without wedge excision, may have already been performed and wedge closure completed. This should not compromise TDR exposure and will facilitate its posterior apical suture site choice. Even in the absence of a transverse defect, these three sutures help support the apex and close the anterior apical gap left from cervical excision. Once satisfied with all support and anterior work, the sutures are tied and held to facilitate removal should cystoscopy reveal a ureteral problem. Thorough intravesical evaluation for sutures and ureteral patency via IV indigo carmine is important following every major anterior and/or apical operation. Failure to see projectile blue dye from one or both ureteral orifices mandates investigation. To our knowledge this is a new modification for anterior apical support and transverse defect repair. We have found no studies of any kind either describing this technique or quantifying its results in the literature since 1966.
PUBOURETHRAL LIGAMENT PLICATION
When performing an anterior colporrhaphy, what is the surgeon to do when the patient complains of stress urinary incontinence and demonstrates urethral hypermobility (UHM) but no urodynamic stress incontinence on urodynamic evaluation? One can repeat the cough stress test. If it remains negative, one may feel hard-pressed to perform a definitive anti-incontinence procedure. This is a good opportunity to perform the single-suture pubourethral ligament plication (PULP), which will decrease UHM and may eliminate SUI. Following an anterior vaginal dissection, the plication is performed. Condensations of pelvic connective tissue between proximal urethra and pubic bone are thoroughly secured with serial Allis clamps anterolaterally at 45 . A single farnear, near-far delayed absorbable suture around both Allis clamps will plicate this pubourethral connective tissue creating a proximal suburethral strap. The lateral bites are deep and the medial bites are superficial. A midline, paravaginal, or any other indicated reconstructive procedure may be performed. Then, redundant vaginal skin is excised and the anterior wall closed with a running 2-0 polygalactin or polyglycolic acid suture. We do not consider this an anti-incontinence procedure; rather a urethral stabilizer.
POSTERIOR COLPORRHAPHY
One ought to clearly know preoperatively the extent to which the rectocele referable symptoms cause patient bother, the posterior compartment pelvic organ prolapse quantification (POP-Q) measurements and stage, and, if possible, the patient's desire for future coital function. A careful rectal exam with two Breisky retractors gently separating the lateral vaginal walls, performed after completion of the anterior, apical, and/ or incontinence portions of the operation will demonstrate the size, extent, and often the etiology of the rectocele. The surgical description that follows is modified from the two-incision, transverse dissection, Bullard-type of posterior colporrhaphy.14 The hymeneal remnants at 4 to 5 and 7 to 8 o'clock are grasped with Glassman or Allis clamps, such that when crossed, the introitus admits three moistened fingers without tightness. The perineal skin incision is marked between the two clamps as a ``V'' when the perineum is only mildly deficient and the vaginal outlet mildly relaxed. It is marked as a ``U''-shaped incision, excising more perineal skin, when there has been more damage to the outlet and perineum. The incision line may be infiltrated with local anesthetic and vasoconstrictor. We use 0.5% bupivacaine in epinephrine 1:200,000 in a control syringe, through a 30-gauge needle, intracutaneously. The incision is usually made with
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a #10 scalpel blade; the second scalpel pass is angled inward at 45 degrees to begin dissection of the perineal skin flap. For the remainder of the posterior dissection, a curved Mayo scissors--directed transversely between the undersurface of the superficial perineal and posterior vaginal epithelium--is used to sharply take all the old obstetrical scar and fibromuscular layer off the epithelium. The scissor tips are held closed and gently advanced transversely in an attempt to get between these two layers (Fig. 6). At the medial aspects of the two previously placed Allis-type clamps, the perineal incision is carried cephalad, up the posterior vaginal wall, creating matching parallel incisions, no less than 1 cm medial to the posterior lateral sulci to allow adequate vaginal caliber for comfortable coitus. This perineal and distal posterior skin flap is held in Allis, or better still, a Krobach clamp. The surgeon's nondominant hand holds this instrument up vertically, with the middle-finger gently pushing on the luminal side of the posterior skin, at the point of dissection. This facilitates entry of the scissor tip into the split-thickness (Bullard) plane. The scissor tip is removed and only its lower blade reinserted, always remaining transverse (Fig. 7). At a point as close as possible to the distal end of the skin flap, the scissor tips are brought together, anatomically freeing all but the superficial epithelium. This dissection continues until an area is fully freed. Then the two matching parallel posterior incisions are carried further up the posterior compartment. As these incisions progress, the Allis clamps are moved up to points just lateral to the furthest extent of the two incisions. As the transverse dissection and two incisions progress cephalad, the connective tissue usually becomes a bit looser and entry into the bluish-tinged rectovaginal space is obtained. The scissors may now be directly cephalad and opened widely revealing the damaged
Fig. 6. Bi-digital proprioception between the nondominant middle finger and the dominant index finger at the fulcrum of the dissection scissor appreciates the proper thickness of posterior skin to achieve and thus, the amount of pressure to place on the scissor tips.
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Fig. 7. The lower scissor blade is inside the connective tissue to be cut and the transversely placed scissor is elevated distally as far as possible, leaving maximal connective tissue in situ.
rectovaginal connective tissue (septum), as shown in Fig. 8. Placement of a selfretaining Rigby retractor intravaginally, while an intrarectal index finger is partially flexed, will clearly define the details, directions, and limits of the connective tissue defects. For repair, we usually close all site-specific defects and then run a vertical plication suture, obtaining apical purchase on the uterosacral or other strong apical tissue. As the plication progresses, we pick up the best available connective tissue with each bite and carry it down for anchoring into the perineal body, thus reestablishing posterior continuity between Delancey levels I, II, and III. For connective tissue plication, we use 2-0 polydiaxonone suture on a CT-2 needle. The redundant posterior vaginal skin is consequently removed in the dissection and the skin is closed, again from apical connective tissue to perineal body, with continuous 2-0 polygalactin suture. As the posterior colporrhaphy is completed and the perineum sits open, awaiting reconstruction, we consider the history, particularly concerning coital dysfunction symptoms: looseness, lack of coital sensation, inability to hold partner in vagina; or alternatively acoital status secondary to whatever reason and importantly, the desire for coital activity in the future. A posterior colporrhaphy and perineorrhaphy may be performed a bit more aggressively, leaving a slightly narrowed vaginal tube and introitus and a long thick perineum. This would likely result in diminished risk of POP recurrence, while making future coitus difficult or impossible. I believe that a fully competent middle-aged or older woman, who is no longer coitally active, ought to be given the right to make a permanent judgment regarding her coital future--if she desires. This result may be achieved without using obliterative procedures (covered by Wheeler elsewhere in this issue).
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Fig. 8. Rectovaginal space entry is confirmed by directing the scissor tips cephalad and pointing anteriorly. Spreading the tips reveals the bluish-tinged open rectovaginal space with the rectovaginal septal connective tissue posteriorly.
For the standard perineorrhaphy in a coitally active woman (or anyone who wants to maintain that option) we plan the vagina and introitus to comfortably accommodate her partner. We try to leave the vagina from hymeneal remnant to apex of a cylindrical-shape that easily admits three-fingerbreadths. ``Crown-stitches'' of 2-0 or 0-polydiaxonone are placed in a mirror image manner, from inside/deep perineal to outside/subcutaneous vulva and back in the opposite way, thus bringing back the retracted ends of the perineal body musculature (bulbocavernosus and transverse perineal muscle) into the new perineal body (Fig. 9). The size and number of these crown-stitches and the needle used (CT-1, CT, or CT-X) will determine the extent of perineal enlargement, lengthening the posterior vagina and controlling introital width. We use between two and five of the sutures. They are placed as the hands of a clock, held and tied after all are placed. Crossing the stitches without tying demonstrates their effect and allows one to determine if they should be made using smaller or larger bites and where the next crown-stitches should be placed. They must not be tied tightly. If there remains a deep perineal gap after the crown stitches are tied, this can be closed with interrupted 2-0 polygalactin. The skin can be approximated with 4-0 monocryl subcuticular interrupted sutures. The vaginal approach to pelvic organ prolapse repair is a superb and natural approach to the effective performance of reconstructive procedures. Through the works of Dr David Nichols and others beginning 40 years ago, as well as the Vaginal Surgeons Society (established in 1974, for many years now the Society of Gynecologic Surgeons), the discipline of vaginal surgery has become a mainstay of benign gynecologic therapy. Over the years, the vaginal approach has proven to be a safe
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Fig. 9. Wide bites with a large needle better secure and reconstitute the retracted ends of the perineal musculature. In a right-handed surgeon, to maximize the effectiveness of the left side bite, the wrist must be open (fully pronated).
and efficacious method of alleviating the disabling effects of pelvic floor dysfunction. Currently, our gastroenterology and general surgery colleagues are beginning to find the ``natural orifice'' in achieving their own intra-abdominal therapeutic goals, while affording their patients the benefit of avoiding an ``unnatural'' incision.
REFERENCES
1. Ricci JV. The development of gynecologic surgery and instruments. San Francisco(CA): Norman Publishing; 1990. 2. Ribeiro SC, Ribeiro RM, Santos NC, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet 2003;83:37�43. 3. Barber MD, Cundiff GW, Weidner AC, et al. Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. Am J Obstet Gynecol 1999;181(1):87�90. 4. Segal JL, Vassallo BJ, Kleeman SD, et al. Paravaginal defects: prevalence and accuracy of preoperative detection. Int Urogynecol J Pelvic Floor Dysfunct 2004;15(6):378�83. 5. Hofmeister FJ. ``Cinefluorography'' [video]. Marquette University Medical School, Milwaukee Hospital, Milwaukee County Hospital, Minnesota. 6. Miller NF. A new method of correcting complete eversion of the vagina: with or without complete prolapse; report of two cases. Surg Gynecol Obstet 1927;44: 550�5. 7. McCall ML. Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol 1957;10:595�602. 8. Montella JM, Morrill MY. Effectiveness of the McCall culdeplasy in maintaining support after vaginal hysterectomy. Int Urogynecol J 2005;16:226�9. 9. Chene G, Tardieu AS, Savary D, et al. Anatomical and functional results of McCall cludoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J 2008;19:1007�11. 10. Elkins TE, Hopper JB, Goodfellow K, et al. Initial report of anatomic and clinical comparison of the sacrospinous ligament fixation to the high McCall culdeplasty
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